Card Range To Study

146 Cards in this Set

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The nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles ofheat and cold application, the nurse would:

1. keep the area covered with the warm soaks continuously.

2. remove the warm compress after 20 minutes for at least 15 minutes.

3. alternate warm compresses with cold compresses.

4. question the order because heat increases edema.

answer: 2
Because heat and cold can injure the skin, either should be applied only for a limited time. Warm compresses increase circulation and promote absorption of fluid in the infiltrated area. Removing the compresses every 20 minutes for at least 15 minutes prevents injury to the skin and subsequent rebound vasoconstriction. Cold compresses, although helping to reduce edema, cause vasoconstriction. Keeping the area covered continuously isn't appropriate because this can lead to skin breakdown.

The nurse is caring for a client who underwent surgical repair of a detached retina of the right eye. Which interventions should the nurse perform?

1. Place the client in a prone position.

2. Approach the client from the left side.

3. Encourage deep breathing and coughing.

4. Discourage bending down.

5. Orient the client to his environment.

6. Administer a stool softener.

Answer: 2,4,5,6
The nurse should approach the client from the left side — the unaffected side — to avoid startling him. She should also discourage the client from bending down, deep breathing, hard coughing and sneezing, and other activities that can increase intraocular pressure. The client should be oriented to his environment to reduce the risk of injury. Stool softeners should be administered to discourage straining during defecation. The client should lie on his back or on the unaffected side to reduce intraocular pressure on the affected eye.

3. Considering a 1" (2.5-cm) edge around the sterile field contaminated

4. Opening the outermost flap of a sterile package away from the body

answer: 2

Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

A client in a behavioral-health facility receives a 30-minute psychotherapy session and the provider bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:

1. unbundling.

2. overbilling.

3. upcoding.

4. misrepresentation.

answer: 3
Upcoding is the practice of using a current procedure terminology code that is reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren't the terms used for this illegal practice.

Which of the following is an example of a primary preventive measure?

1. Participating in a cardiac rehabilitation program

2. Obtaining an annual physical examination

3. Practicing monthly breast self-examination

4. Avoiding overexposure to the sun

answer: 4
Primary prevention involves promoting health and helping clients achieve maximum wellness. Primary preventive measures are designed to prevent or delay the onset of specific illnesses; typically, these measures include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer. Participating in a cardiac rehabilitation program is an example of a tertiary preventive measure, which attempts to prevent complications of an existing disease. Annual physical examinations and monthly breast self-examinations are examples of secondary preventive measures, which promote early detection and treatment of disease.

Nursing care for a client includes removing elastic stockings once per day. What is the rationale for this intervention?

1. To increase blood flow to the heart

2. To observe the lower extremities

3. To allow the leg muscles to stretch and relax

4. To permit veins in the legs to fill with blood

answer: 2

Nursing care for a client includes removing elastic stockings once per day. What is the rationale for this intervention?

1. To increase blood flow to the heart

2. To observe the lower extremities

3. To allow the leg muscles to stretch and relax

4. To permit veins in the legs to fill with blood

answer: 4
Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the most accurate indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration; although helpful, it isn't the most accurate indicator because it can be influenced by numerous factors.

Omnibus Reconciliation Act of 1986?
All families of clients who are nearing death, or have died, must be approached with the option of organ and tissue donation.

Omnibus Reconciliation Act of 1986:
all hospitals establish written protocols for the identification of potential organ and tissue donors. The act sets standards for organ procurement agencies. The medical examiner should be notified if the client is a potential organ or tissue donor only if the medical examiner is involved in the case. Requesters for donation are health care professionals who have received special training on properly approaching family members regarding organ or tissue donation.

A laissez-faire nurse-manager takes which action?

1. Completes the vacation schedule without input from staff

2. Delegates responsibility for the evaluation of the effectiveness of a new piece of equipment to the staff members who use it

3. Identifies possible solutions to staffing problems and asks staff for their opinions about each

4. Delegates responsibility for selecting a new nursing care delivery system to staff

Answer: 4
Delegation of a process that will affect all aspects of a nursing area shows a lack of accountability characteristic of a laissez-faire manager. Making critical decisions without staff input is characteristic of an autocratic manager. Delegating evaluation to staff who are intimately involved in a project is appropriate and characteristic of a democratic manager. Identifying potential solutions to a problem and asking staff for their opinions of the solutions is characteristic of a participative manager.

cystic fibrosis diet:
Encourage a high-calorie, high-protein diet.

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A nurse manages a unit that has four full-time vacant positions, and nurses volunteer to work extra shifts to cover the staffing shortages. One of the staff nurses hasn't volunteered and states, "Forty hours a week of nursing is all I can manage to do. I won't volunteer for overtime." The nurse-manager says to an attending physician on the unit, "I'll adjust her schedule to make her wish she'd volunteered." The physician to whom she commentedshould:

1. choose to ignore the comment because it isn't the physician's domain.

2. report the nurse-manager to the labor relations board.

3. ensure that the nurse-manager receives counseling about her comment.

4. tell the staff nurse what the manager said about her

answer: 3
It's discriminatory and punitive for the nurse-manager to alter the staff nurse's schedule. The remark is inappropriate and unprofessional, and the nurse-manager should receive counseling. The physician could choose to ignore the comment, but any provider who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the nurse-manager to the labor relations board should be avoided. Institutional documentation should exist for such matters. It's inappropriate for the physician to inform the staff nurse about what was said. Such action could create difficult relations on the unit and thereby affect nursing care.

When discussing the Food Guide Pyramid with a 75-year-old client, the nurse should remember that the guide has been modified for older people. Unlike the standard Food Guide Pyramid, the version for elderly individuals:

1. includes eight 8-oz glasses of water at the base of the pyramid.

2. sets upper limits on servings of most food and water.

3. increases the amounts of recommended milk and dairy products.

4. eliminates the portion of the pyramid for fats, oils, and sweets.

answer: 1
The Food Guide Pyramid version for older people adds a base that includes eight 8-oz glasses of water to prevent constipation and dehydration. The pyramid sets no upper limits on servings of most food and water. It doesn't increase the milk and dairy recommendation and doesn't eliminate the fats, oils, and sweets recommendation.

The physician orders an intestinal tube to decompress a client's GI tract. When gathering equipment for this procedure, the nurseidentifies which of the following as an intestinal tube?

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client education materials. Which statement illustrates thebest method of delegation?
Tell the nursing staff they're responsible for the review and revision and that their recommendations for improving the materials are welcome.

2. Ask the two best staff nurses to form a task force to review and revise client education materials within the next 6 weeks. Have them solicit input from clients and staff members.

3. Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change.

4. Ask the assistant manager to develop a plan for the review and revision of client education materials.

answer: 2
Delegation must be done clearly and precisely. The nurse-manager must assign responsibility, identify the task to be accomplished, explain what outcomes are needed, and the time frame for completing the work. The remaining options don't give clear explanations of work to be done, don't clearly assign responsibility or the specific outcomes desired, or establish a time frame for completion of the task.

The physician has ordered a wet-to-dry dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to accomplish which action?

1. Preventing the spread of the infection

2. Debriding the wound

3. Keeping the wound moist

4. Reducing pain

Correct Answer: 2
Because dead tissue adheres to a dry dressing, wet-to-dry dressings are used for debriding wounds. The wound isn't kept moist and wet-to-dry dressings don't prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.

The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When the nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using thenew procedures. Which action should the nurse-manager take?

1. Determine that the procedures currently in place must be followed and direct staff to follow them without question.

2. Tell staff members to use whatever procedures they feel are best.

3. Ask staff members to quickly meet among themselves and decide what procedures to follow.

4. Tell staff members to assemble in the staff lounge; there the nurse-manager will quickly gather opinions about evacuation procedures before deciding what to do.

Correct Answer: 1
In an emergency such as a bomb scare, the nurse-manager must determine, without hesitation, the best action for the safety and welfare of clients and staff. Allowing staff members to do whatever they think best will cause confusion and inefficient client evacuation because no one will know how to function effectively as a team during the crisis. Taking time to have a staff meet is wasting valuable time.

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicateseffective teaching?

1. "I will administer the enema while sitting on the toilet."

2. "I will administer the enema while lying on my left side with my right knee flexed."

3. "I will administer the enema while lying on my right side with my left knee flexed."

4. "I will administer the enema while lying on my back with both knees flexed

Correct Answer: 2
Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and therefore are less effective in evacuating the lower bowel.

The managers of the physical and occupational therapy neurologic departments have expressed concern to the nurse-manager of an adult neurologic rehabilitation unit that clients have been arriving late for therapy. In response, the nursing staff of the rehabilitation unit has complained that therapy schedules don't allow sufficient time for performing nursing interventions. Which action by the nurse-manager is thebest solution to this problem?

1. Meet with the managers of physical and occupational therapy and determine how to reschedule clients; then inform the nursing staff.

2. Tell the nursing staff that they need to determine how to transport clients to therapy according to the schedules developed by the therapists.

4. Ask several staff nurses to work with the therapy staff to help solve the scheduling problem and offer herself as a resource.

Correct Answer: 4
In this situation, functioning as a democratic leader is best. The nursing and therapy staffs who deal with the day-to-day problems of direct client care have the best grasp of the situation and should have autonomy to solve problems. The manager, however, should be available to help. Option 1 reflects an autocratic manager. Without staff input, the nurse-manager won't have the necessary information to identify the best solution. By simply telling the nursing staff to follow the therapists' schedules, the nurse-manager has abdicated responsibility for problem solving (laissez-faire manager), yet the problem still exists. Determining problem-solving options without staff input is indicative of a participative manager. A participative manager asks staff members for opinions, but they don't have input into actual problem solving. This lack of input may lead to resentment and frustration.

What does the nurse do when making a surgical bed?

1. Leaves the bed in the high position when finished

2. Places the pillow at the head of the bed

3. Rolls the client to the far side of the bed

4. Tucks the top sheet and blanket under the bottom of the bed

Correct Answer: 1
When making a surgical bed, the nurse leaves the bed in the high position when finished. After placing the top linens on the bed without touching them, the nurse fanfolds these linens to the side opposite from where the client will enter and places the pillow on the bedside chair. All of these actions promote transfer of the postoperative client from the stretcher to the bed. When making an occupied or unoccupied bed, the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse rolls the client to the far side of the bed.

The physician orders a bland, full-liquid diet for a client. The nurse understands that this client's diet may include:

1. orange juice, farina, and coffee.

2. apple juice, cream of chicken soup, and vanilla ice cream.

3. pineapple juice, a bran muffin, and milk.

4. orange juice, custard, and tea.

Correct Answer: 2
: A bland, full-liquid diet may include fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods.

Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would bemost therapeutic for this client?

1. Semi-Fowler's

2. Supine

3. High-Fowler's

4. Side-lying

Correct Answer: 4
Because of lethargy, the posttonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he's fully awake is best. The semi-Fowler, supine, and high-Fowler positions don't allow for adequate oral drainage of a lethargic posttonsillectomy client and increase the risk of blood aspiration.

A postoperative client receives a lunch tray with milk, custard, and vanilla ice cream. What is the client's current diet order?

1. American Dietetic Association Exchange diet

2. Full-liquid diet

3. Clear liquid diet

4. BRAT diet

Correct Answer: 2
A full-liquid diet consists of fluids and foods that are liquid at room temperature. Some examples are milk, custard, ice cream, puddings, vegetable and fruit juices, refined or strained cereals, and egg substitutes. A full-liquid diet also includes all foods allowed on a clear liquid diet. Although these foods may be included in a diatetic exchange diet, there aren't enough food choices to indicate that this is a diatetic exchange diet. A clear-liquid diet includes transparent liquids, such as apple juice, ginger ale, and chicken broth. The BRAT diet is commonly used to combat diarrhea and limits intake to bananas, rice, applesauce, and toast.

The care plan is revised for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan includeearly in this mother's hospital stay?

1. Anger management therapy

2. Proper care of a crying infant

3. Proper methods for dealing with stressful situations such as crying infants

4. Assessment of the mother's strengths and weaknesses in coping mechanisms and the presence or absence of support systems

Correct Answer: 4
Assessment of the mother's strengths and weaknesses in her coping mechanisms and the presence or absence of support systems is important in the implementation process. Assessment will also help identify situations that the mother perceives as stressors. Providing education about alternative ways of expressing feelings and about crisis hotlines and community support systems should also be part of the care plan. It hasn't been established that the mother is angry, so anger management therapy may not be necessary. Proper care of a crying infant is necessary, but assessing the mother's coping will help provide the basis for teaching.

During a teaching session, the nurse demonstrates how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure?

1. The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide.

2. The client rinses around the clean incision site, using gauze squares moistened with normal saline.

3. The client rinses around the clean incision site, using gauze squares moistened with tap water.

4. The client applies cotton-filled gauze squares as the sterile dressing after cleaning.

Correct Answer: 2

Which of the following is an example of a primary preventive measure?

1. Participating in a cardiac rehabilitation program

2. Obtaining an annual physical examination

3. Practicing monthly breast self-examination

4. Avoiding overexposure to the sun

Correct Answer: 4
Primary prevention involves promoting health and helping clients achieve maximum wellness. Primary preventive measures are designed to prevent or delay the onset of specific illnesses; typically, these measures include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer. Participating in a cardiac rehabilitation program is an example of a tertiary preventive measure, which attempts to prevent complications of an existing disease. Annual physical examinations and monthly breast self-examinations are examples of secondary preventive measures, which promote early detection and treatment of disease.

A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after his admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action would bemost appropriate at this time?

Correct Answer: 4
The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's response without question or further assessment may lead to inadequate intervention. Calling the family or giving pain medication isn't warranted because the client denies pain.

A child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the child's pain?

1. Perform gentle passive range-of-motion exercises.

2. Gently massage the painful joints.

3. Use a bed cradle to keep linens off the child's joints.

4. Encourage the child to change position in bed every 2 hours.

Correct Answer: 3

In rheumatic fever, the joints may be so painful that even the weight of the bed linens can cause pain. A bed cradle lifts the weight of the linens off the child, reducing pain. Pain may be increased when the affected joint is moved; therefore, passive range-of-motion exercises aren't recommended. Pain isn't likely to be relieved by massaging the joints. The child should be encouraged to change positions at least every 2 hours to reduce the risk of skin breakdown, but this is unlikely to relieve joint pain.

The nurse is assisting a client with lower motor neuron damage who has difficulty with urination. The nurse shows the client how to apply gentle pressure over the lower abdomen to empty thebladder. By what name does the nurse refer to this procedure?

1. Valsalva's maneuver

2. Credé's method

3. Credé's maneuver

4. Leopold's maneuvers

Correct Answer: 3
Credé's maneuver is performed by applying manual pressure over the lower abdomen. This procedure promotes complete emptying of the bladder in clients with lower motor neuron damage that impairs the voiding reflex. Valsalva's maneuver triggers vagal stimulation of the heart. During this maneuver, the client is instructed to take a deep breath and bear down as if defecating. It's commonly used to help terminate atrial arrhythmias. Credé's method is used when a 1% solution of silver nitrate is instilled into a neonate's eyes to prevent gonorrheal conjunctivitis caused by Neisseria gonorrhoeae. Leopold's maneuvers are used to determine fetal position.

The nurse is assigned to a client with a cardiac disorder. When monitoring body temperature for this client, the nurse should avoid which route?

1. Rectal

2. Oral

3. Axillary

4. Tympanic

Correct Answer: 1
When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature because it may stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

When approaching a family for organ or tissue donation, the nurse should keep in mind which guideline?

1. Approaching a family is done only with a physician's approval and written order.

2. The requester doesn't have to believe in the benefits of organ donation but should support the process with a positive attitude.

3. The requester is knowledgeable about the basics of organ and tissue donation and is capable of educating the family members about brain death early in the organ donation process.

4. The family is offered an opportunity to speak with an organ procurement coordinator.

Correct Answer: 4
The family should be offered an opportunity to speak with an organ procurement coordinator. An organ procurement coordinator is knowledgeable about the organ donation process and should have exceptional interpersonal skills for dealing with grieving family members. Physician support in the process is desirable but consent or written orders aren't necessary for a referral to the organ procurement organization. The requestor must believe in the benefits of organ donation and support the process with a positive attitude. The family should be approached about speaking to an organ procurement coordinator only after the family has been made aware of the client's condition and prognosis. Approaching a family member who believes there's still hope for recovery will likely result in a negative outcome.

Which action would be contraindicated for a client who develops a temperature of 102° F (38.9° C).

1. Monitoring temperature every 4 hours

2. Increasing fluid intake

3. Covering the client with a light blanket

4. Providing a low-calorie diet

Correct Answer: 4
A client with a fever has an increased basal metabolism rate. Therefore, he needs additional calories in his diet. All the other responses — monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket — are therapeutic interventions for a fever.

A client's attorney can file a lawsuit within which time frame?

1. Discovery rule

2. Statute of limitations

3. Grace period

4. Alternative dispute resolution

Correct Answer: 2
Statute of limitations is the time period during which a case must be filed or the injured party is barred from bringing the lawsuit. Discovery rule is the actual term for when the client has discovered the injury. The statute of limitations typically gives clients 2 years from the time of discovery to file a lawsuit; however, the time may vary from state to state. Grace period refers to any period specified in a contract during which payment is permitted, without penalty, beyond the due date of the debt. Alternative dispute resolution refers to any means of settling disputes outside the courtroom setting.

A severe winter storm has prevented most of the staff members from getting to work on a busy medical-surgical unit. One registered nurse, two licensed practical nurses, and three nursing assistants have been able to get to work. The nurse-manager must decide which nursing care delivery system should be implemented for the best possible client care during this staffingcrisis. The nurse-manager directs the staff to implement which delivery system?

1. Team nursing

2. Primary nursing

3. Functional nursing

4. Case management

Correct Answer: 3
Functional nursing best uses the skills of all staff in a timely manner during this crisis. This delivery system requires the least staff and delegates tasks to those who can best perform them. Team nursing doesn't allow for the best use of a limited number of staff who must care for a large number of clients. Primary nursing and case management require more registered nurses than are currently available.

When providing oral hygiene for an unconscious client, the nurse must take which essential action?

1. Swabbing the client's lips, teeth, and gums with lemon glycerin

2. Cleaning the client's tongue with gloved fingers

3. Placing the client in semi-Fowler's position

4. Placing the client in a side-lying position

Correct Answer: 4
An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning the tongue with gloved fingers wouldn't be effective in removing oral secretions or debris in an unconscious client. Placing the client in semi-Fowler's position would increase the risk of aspiration.

The client's rights to information, informed consent, and treatment refusal are addressed in the:

1. standards of nursing practice.

2. client's bill of rights.

3. nurse practice act.

4. code for nurses.

Correct Answer: 2

A nurse-manager receives several complaints from day-shift nurses that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would bemost prudent for the nurse-manager to:

1. immediately remind the night-shift nurses of the daily calibrations.

2. arrange a meeting of the day-shift and night-shift nurses.

3. review the capillary glucose monitoring calibration log book.

4. counsel the night charge nurse about the discrepancy

Correct Answer: 3

Four clients injured in an automobile accident enter the emergency department at the same time and are immediately seen by the triage nurse. The nurse would assign thehighest priority to the client with the:

1. lumbar spinal cord injury and lower extremity paralysis.

2. maxillofacial injury and gurgling respirations.

3. severe head injury and no blood pressure.

4. second trimester pregnancy in premature labor.

Correct Answer: 2
Emergency department triage involves giving priority to clients at highest risk for loss of life, limb, or vision. Clients with poor prognoses are given a lesser priority. The client with the maxillofacial injury and gurgling respirations needs immediate attention because of an impaired airway. The spinal cord injury client doesn't exhibit immediate airway needs. The client with the severe head injury and no blood pressure has a grave prognosis. Although the client in early labor is an urgent priority, early labor doesn't surpass airway compromise in importance.

For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should the nurse include in the assessment?

1. "Does the pain worsen in the morning upon rising?"

2. "Does the pain increase with activity and lessen with rest?"

3. "Is the pain relieved by position changes?"

4. "Is the pain worse with the toes pointed toward the knee?"

Correct Answer: 4
The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes toward the knee will elicit discomfort. The time of the day doesn't influence the pain associated with DVT. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. A dependent position will increase venous stasis and the pain associated with DVT.

A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can be grouped fairly easily by geographic location and client care needs, the nurse-manager and her staffappropriately decide to implement which NCDS?

1. Functional nursing

2. Case management

3. Team nursing

4. Primary nursing

Correct Answer: 3
Team nursing is efficient and costs less to implement than primary or case management systems. Because the staff members know each other well, they can function effectively as a team. Although functional nursing is the most cost effective, care is commonly fragmented and client satisfaction decreased. Case management and primary nursing require more registered nurses than are available.

Which intervention should the nurse use when administering oxygen by face mask to a client?

1. Secure the elastic band tightly around the client's head.

2. Assist the client to the semi-Fowler position if possible.

3. Apply the face mask from the client's chin up over the nose.

4. Loosen the connectors between the oxygen equipment and humidifier

Answer: 2
By assisting the client to the semi-Fowler position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could lead to irritation. The nurse should apply the face mask from the client's nose down to the chin — not vice versa. The nurse should check the connectors between the oxygen equipment and humidifier to ensure that they're airtight; loosened connectors can cause loss of oxygen.

The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include:

The nurse-manager of a 20-bed coronary care unit isn't on duty when a staff nurse makes a serious medication error. The client, who received an overdose of medication, nearly dies. Which statement accurately reflects theaccountability of the nurse-manager?

1. The nursing supervisor will notify the nurse-manager at home.

2. The nurse-manager is off duty, therefore it isn't necessary to notify her.

3. The nurse-manager should be informed on Monday when she returns to duty.

4. Although the nurse-manager is off duty, the nursing supervisor decides to call the nurse-manager if time permits

Correct Answer: 1
The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible. The other choices don't accurately reflect the accountability of the nurse-manager's position.

Which member of the health care team is responsible for obtaining informed consent from a client?

1. The primary nurse

2. The physician

3. The nurse working with the physician

4. The physician's assistant

Correct Answer: 2
The physician involved with the procedure is responsible for obtaining the client's informed consent. The primary nurse or the nurse working with the physician may serve as a witness to the client's signature. In some health care facilities, a physician's assistant may obtain informed consent; however, in this case, a physician must act as cosigner.

A nurse-manager works for a nonprofit health care corporation in which there has been significant revenue over expenses for the year. The nurse-manager has been told to anticipate which action?

1. Receipt of a portion of the revenue to improve client services on the unit

2. Identification of revenue as profit

3. Division of revenue among stockholders as dividends

4. Reduction of operating expenses to help the organization pay taxes on the revenue

Correct Answer: 1
Revenue over expenses in a nonprofit organization is tax-exempt and is usually reinvested in the organization and used to improve services. A for-profit organization calls its revenue over expenses a profit and the revenue can be divided as a dividend among stockholders or reinvested in the organization.

A nurse works on a general medical-surgical unit where nurses work on 12-client pods. Each pod is staffed by two registered nurses. When one of the nurses leaves the unit for any reason, the remaining nurse cares for all 12 clients. If she needs help, she can call the agency's in-house resource nurse. One evening, when acoworker nurse left the unit, the remaining nurse, who was making rounds on the departed nurse's clients, found medications left at bedsides and a client with a blood-draw tourniquet remaining on his arm. In addressing the problems, the nurse should:

1. inform the nurse-supervisor right away.

2. correct the problems and submit a written report.

3. speak to the coworker when she returns to the unit.

4. ask for a meeting with the coworker and a manager.

Correct Answer: 3
When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed by only those directly involved.

A client in a behavioral-health facility receives a 30-minute psychotherapy session and the provider bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:

1. unbundling.

2. overbilling.

3. upcoding.

4. misrepresentation.

Correct Answer: 3
Upcoding is the practice of using a current procedure terminology code that is reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren't the terms used for this illegal practice

Performance improvement is an important component of continuous quality improvement. Which action should an effective nurse-manager take when conducting performance evaluations?

1. Conduct performance evaluations in a group setting so input from peers and subordinates is considered when evaluating a staff member's effectiveness.

2. Provide feedback on strengths as well as areas for improvement and clarify what the staff member is expected to accomplish before the next performance evaluation.

3. Document areas for improvement in writing. Areas of strength don't need to be documented because these areas are complimentary and don't describe actions the staff member must take to improve.

Correct Answer: 2
An effective performance evaluation provides recognition of strengths, identifies areas for improvement, and clarifies performance expectations. Performance evaluations should be done in private, not in front of others. All components of a performance evaluation should be documented in writing. Although input from staff members can be useful in preparing performance evaluations, delegating all responsibility to others is inappropriate. The nurse-manager is responsible for the performance of the staff.

A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do?

1. Prevent the client from leaving.

2. Notify the physician.

3. Have the client sign an AMA form.

4. Call a security guard to help detain the client.

Correct Answer: 2
If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left.

A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:

1. unhappiness about the change in leadership.

2. unexpressed feelings and emotions among the staff.

3. fatigue from overwork and understaffing.

4. failure to incorporate staff in decision making.

Correct Answer: 2
The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpressed feelings and emotions. Although the other answers could be contributing to the problematic situation, they're less likely to be the cause.

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which of the following actions can the nurse institute independently?

1. Using a povidone-iodine wash on the ulceration three times per day

2. Using a normal saline solution to clean the ulcer and applying a protective dressing as necessary

3. Applying an antibiotic cream to the area three times per day

4. Massaging the area with an astringent every 2 hours

Correct Answer: 2
Washing the area with normal saline solution and applying a protective dressing are within the nurse's realm of interventions and will protect the area. Using a povidone-iodine wash and an antibiotic cream require a physician's order. Massaging with an astringent can further damage the skin.

A laissez-faire nurse-manager takes which action?

1. Completes the vacation schedule without input from staff

2. Delegates responsibility for the evaluation of the effectiveness of a new piece of equipment to the staff members who use it

3. Identifies possible solutions to staffing problems and asks staff for their opinions about each

4. Delegates responsibility for selecting a new nursing care delivery system to staff

Correct Answer: 4
Delegation of a process that will affect all aspects of a nursing area shows a lack of accountability characteristic of a laissez-faire manager. Making critical decisions without staff input is characteristic of an autocratic manager. Delegating evaluation to staff who are intimately involved in a project is appropriate and characteristic of a democratic manager. Identifying potential solutions to a problem and asking staff for their opinions of the solutions is characteristic of a participative manager.

The nurse is preparing to boost a client up in bed and instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?

1. Friction

2. Impaired circulation

3. Localized pressure

4. Shearing forces

Correct Answer: 4
Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) increase the risk of pressure ulcer development. They can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees.

The manager of an outpatient clinic is explaining the various health care delivery systems to a client who's interested in joining a system with a reasonablefixed capitation rate. Which organization is the client primarily interested in joining?

1. A preferred provider organization (PPO)

2. A managed-care organization

3. A health-maintenance organization (HMO)

4. A privately funded insurance company

Correct Answer: 3
An HMO provides comprehensive health services for a fixed rate of payment or capitation. A PPO pays health care expenses for members if they use a provider who's under contract to that PPO. Managed care provides beneficiaries with a variety of services for an established, agreed upon payment. A privately funded insurance company won't offer services for a fixed rate.

The nurse is preparing to help a client with weakness in his right leg get out of bed to a chair. Where should the nurse place the chair?

1. Parallel to the bed on the right side

2. Perpendicular to the bed on the right side

3. Parallel to the bed on the left side

4. Parallel to the bed on either side

Correct Answer: 1
The client can maintain his weight and pivot with his left foot if the chair is placed on his right side parallel to the bed. The nurse shouldn't place the chair on his left side or perpendicular to the bed because the client won't be able to support his weight on his right leg.

Which nursing action is essential when providing continuous enteral feeding?

1. Elevating the head of the bed

2. Positioning the client on the left side

3. Warming the formula before administering it

4. Adding methylene blue to the feeding to detect aspiration

Correct Answer: 1
Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on his right side. The nurse should give enteral feedings at room temperature to minimize GI distress. Because methylene blue can cause adverse effects, it's no longer a recommended enteral feeding additive.

A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have amammogram how often?

1. Once, to establish a baseline

2. Once per year

3. Every 2 years

4. Twice per year

Correct Answer: 2
Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks, such as family history, genetic tendency, or past breast cancer, exist, more frequent examinations may be necessary.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will occurnext?

1. The incident will be reported to the state board of nursing for disciplinary action.

2. The incident will be documented in the nurse's personnel file.

3. The medication error will result in the nurse being suspended and, possibly, terminated from employment at the facility.

4. The incident report is a method of promoting quality care and risk management.

Correct Answer: 4
Unusual occurrences and deviations from care are documented on incident reports. Incident reports are internal to the facility and are used to evaluate care, determine potential risks, or discover system problems that could have attributed to the error. This type of error won't result in a report to the state board of nursing or in suspension of the nurse. Some facilities do track the number of errors by a nurse or on particular units; the purpose of tracking errors is to provide appropriate education and to improve the nursing process.

The selection of a nursing care delivery system (NCDS) is critical to the success of a nursing area. Which factor is essential to the evaluation of a NCDS?

1. Determining how planned absences, such as vacation time, will be scheduled so that all staff are treated fairly

2. Identifying who will be responsible for making client care decisions

3. Deciding what type of dress code will be implemented

4. Identifying salary ranges for various types of staff

Correct Answer: 2
Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress code, salary, and scheduling planned staff absences are important to any organization but aren't actually determined by the NCDS.

The nurse is teaching a client with left leg weakness to walk with a cane. The nurse should instruct the client to proceed in which manner?

1. Hold the cane on the left side 4″ to 6″ from the base of his little toe.

2. Hold the cane away from the body.

3. Move the cane and the right leg simultaneously.

4. Hold the cane in the right hand.

Correct Answer: 4
To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg 4″ to 6″ from the base of the little toe. Therefore, this client should hold the cane in his right hand. The client should hold the cane close to his body to prevent leaning and he should move the cane and the involved leg (left, in this case) simultaneously, then move the uninvolved leg.

Which assessment finding by the nurse contraindicates the application of a heating pad?

1. Active bleeding

2. Reddened abscess

3. Edematous lower leg

4. Purulent wound drainage

Answer: 1
Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

A 62-year-old client has just been diagnosed with terminal cancer and is being transferred to home hospice care. The client's daughter tells the nurse, "I don't know what to say to my mother if she asks me if she's going to die." Which of the following responses by the nurse would be appropriate?

1. "Don't worry, your mother still has some time left."

2. "Let's talk about your mother's illness and how it will progress."

3. "You sound like you have some questions about your mother dying. Let's talk about that."

4. "Don't worry, hospice will take care of your mother."

5. "Tell me how you're feeling about your mother dying."

Correct Answer: 2,3,5
Conveying information and providing clear communication can alleviate fears and strengthen the individual's sense of control. Encouraging verbalization of feelings helps build a therapeutic relationship based on trust and reduces anxiety. Telling the daughter not to worry ignores her feelings and discourages further communication.

The nurse is assessing a client for lifestyle factors that might affect normal coping. Which factor would the nurse most likely consider?

1. Inadequate diet

2. Divorce

3. Job promotion

4. Adopting a child

Correct Answer: 1
Poor, inadequate diet is the only option considered a lifestyle factor. The other choices — divorce, job promotion, and adopting a child — are considered life events.

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which of the following interventionsshould the nurse implement?

1. Discuss the client's concern with the husband.

2. Refer the client to a psychiatrist.

3. Invite a client with a similar experience to speak with the client.

4. Refer the client to a sex therapist.

Correct Answer: 3
Having someone who has had a similar surgery and concerns speak to the client would be beneficial. The client is coping normally and doesn't need professional help. Discussing the concerns with the client's husband doesn't address the client's needs. In fact, the client may feel that the nurse violated confidentiality.

While providing care to a 26-year-old married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped." How should the nurse respond?

1. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries.

2. Report suspicions of abuse to the local authorities.

3. Assist the client in developing a safety plan for times of increased violence.

4. Call the client's husband to discuss the situation.

5. Tell the client that she needs to leave the abusive situation as soon as possible.

6. Provide the client with telephone numbers of local shelters and safe houses.

Correct Answer: 1,3,6
RATIONALES: The nurse should objectively document her assessment findings. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. All women suspected to be victims of abuse should be counseled on a safety plan, which consists of recognizing escalating violence within the family and formulating a plan to exit quickly. The nurse shouldn't report this suspicion of abuse because the client is a competent adult who has the right to self-determination. Nurses do, however, have a duty to report cases of actual or suspected abuse in children or elderly clients. Contacting the client's husband without her consent violates confidentiality. The nurse should respond to the client in a nonthreatening manner that promotes trust, rather than ordering her to break off her relationship.

An obese client is admitted to the facility for abusing amphetamines in an attempt to lose weight. Which nursing intervention isappropriate for this client?

1. Encouraging the client to suppress his feelings regarding obesity

2. Reinforcing the client's concerns over physical appearance

3. Using an abrupt, forceful manner to communicate with the client

4. Teaching the client alternative ways to lose weight

Correct Answer: 4
Teaching the client alternative ways to lose weight is the appropriate intervention. Instead of encouraging the client to suppress his feelings, the nurse should encourage him to express his feelings, especially those related to obesity. Reinforcing the client's concerns about physical appearance may make the client's anxiety worse and lead to more self-destructive behavior. Using an abrupt, forceful manner discourages therapeutic communication with the client.

The nurse is assessing a newly admitted client. When filling out the family assessment, who should the nurse consider to be a part of the client's family?

1. People related by blood or marriage

2. All the people whom the client views as family

3. People who live in the same house

4. People who the nurse thinks are important to the client

5. People who live in the same house with the same racial background as the client

6. People who provide for the physical and emotional needs of the client

Correct Answer: 2,6
When providing care to a client, the nurse should consider family members to be all the people whom the client views as family. Family members may also include those people who provide for the physical and emotional needs of the client. The traditional definition of a family has changed and may include people not related by blood or marriage, those of a different racial background, and those who may not live in the same house as the client. Family members are defined by the client, not by the nurse.

Elisabeth Kubler-Ross identifies five stages of death and dying. Loss, grief, and intense sadness are symptoms of which stage?

1. Denial and isolation

2. Depression

3. Anger

4. Bargaining

Correct Answer: 2
According to Kubler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining, depression, and acceptance. Loss, grief, and intense sadness indicate depression.

Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching?

1. To determine whether the client is psychologically ready for surgery

2. To express concerns to the client about the surgery

3. To reduce the risk of postoperative complications

4. To explain the risks and obtain informed consent

Correct Answer: 3
Preoperative teaching helps reduce the risk of postoperative complications by telling the client what to expect and providing a chance to practice before surgery any required postoperative activities, such as breathing and leg exercises. The physician — not the nurse — is responsible for determining the client's psychological readiness. It's inappropriate for the nurse to express personal concerns about surgery to a client. The physician should describe alternative treatments and explain the risks of surgery to the client when obtaining informed consent.

The nurse writes the following note in the client's chart: "The physician is incompetent because he ordered the wrong drug dosage." This statement may lead to acharge of:

1. assault.

2. slander.

3. battery.

4. libel.

Answer: 4
Libel refers to written communication that injures a person's reputation. Assault is an unjustifiable attempt or threat to touch or injure another person. Slander is oral communication that injures a person's reputation. Battery refers to touching another person unlawfully or carrying out threatened physical harm.

Which of the following changes is demonstrated when a nurse helps a young mother adjust to the birth of her child?

1. Unplanned

2. Situational

3. Maturational

4. Physiologic

Correct Answer: 2
Adjustment to the birth of a child is an example of a situational change, which arises from the interaction between individuals and the environment. Because pregnancy is a 9-month process, the change isn't unplanned. Adjustment to maturational change refers to that associated with puberty. Physiologic change refers to the events associated with aging and menopause.

The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client?

1. Illness in one family member can affect all members.

2. Family roles don't change because of illness.

3. A family member may have more than one role at a time in a family.

4. Children typically aren't affected by adult illness.

5. The effects of an illness on a family depend on the stage of the family's life cycle.

6. Changes in sleeping and eating patterns may be signs of stress in a family.

Correct Answer: 1,3,5,6
Illness in one family member can affect all family members, even children. Each member of a family may have several roles to perform. A middle-aged woman, for example, may have the roles of mother, wage-earner, wife, and housekeeper. Families move through certain predictable life cycles (such as birth of a baby, a growing family, adult children leaving home, and grandparenting). The impact of illness on the family may depend on the stage of the life cycle as family members take on different roles and the family structure changes. Illness produces stress in families; changes in eating and sleeping patterns are signs of stress. When one family member can't fulfill a role because of illness, the roles of the other family members are affected.

A nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be most helpful?

1. Calling a family meeting to tell the absent children that they must participate in helping the client

2. Suggesting the spouse seek psychological counseling to help cope with exhaustion

3. Recommending community resources for adult day care and respite care

4. Encouraging the spouse to talk about the difficulties involved in caring for a loved one with Alzheimer's disease

5. Asking whether friends or church members can help with errands or provide short periods of relief

6. Recommending that the client be placed in a long-term care facility

Correct Answer: 3,4,5
Many community services exist for Alzheimer's clients and their families. Encouraging use of these resources may make it possible for the client to stay at home and to alleviate the spouse's exhaustion. The nurse can also support the caregiver by urging her to talk about the difficulties she's facing in caring for a spouse. Friends and church members may be able to help provide care to the client, allowing the caregiver time for rest, exercise, or an enjoyable activity. A family meeting to tell the children to participate more would probably be ineffective and may evoke anger or guilt. Counseling may be helpful, but it wouldn't alleviate the caregiver's physical exhaustion and wouldn't address the client's immediate needs. A long-term care facility is not an option until the family is ready to make that decision.

A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action should the nurse include in the care plan?

1. Prohibiting personal belongings at the bedside

2. Involving the family and client in planning care

3. Providing detailed explanations of conditions and treatment

4. Allowing the family to visit only when the client asks to see them

Correct Answer: 2
For a client with a nursing diagnosis of Social isolation, interventions include involving the family and client in planning care and encouraging visits from family members and friends. Prohibiting personal belongings at the bedside would increase feelings of isolation. The nurse should provide simple, not detailed, explanations to the client and family because stress may have diminished their comprehension. The nurse should encourage the family to visit as often as the client's condition permits.

When a pt.is in DNR, he is in low priority for care.

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S/S of hypophosphatemia:

irritability,
muscle weakness
paresthesia
mental confusion

-

many medications can cause confusion or depression (not psychoti behaviror) in a geriatric pt.

-

to prevent the stomatitis after chemotherapty, it is important to keep good oral hygiene ( use a nonabrasive toothpaste to brush teeth after meals, and floss every 24 hours. ), not just rinse the mouth.

-B.
hydrate the pt. to promote urinary excretion of Ca.
Other choices can be given after the pt. is hydrated.

hypercalcemia pt. discharge teaching:

stay active and walk as much as possible.

-

When Albumin level is low, Ca level is usually low
(portion of Ca in blood is bound to protein.)

in blood, Ca exists in 3 forms: free or ionized
bound to protein
complexed with phosphate, citrate, or carbonate

Sercum Ca reflects all three forms of Ca.

-

Hypokalemia:

Muscle weakness,
hyporeflexia
constipation
flat/inverted T wave

-

deep breathing exercises:

do every 1 to 2 hours.

-

the doctor's order: Grain X daily for pt with transient ischemic attack. the nurse gets 300-mg tablets from the pharmacy. how many tablets shouldy you administer?

-2 tablets.

grains X = 10 grains = 600 mg.
so need 2 tablets

morphine: a controlled meds, must be locked up. Each individual dose must be accounted for when it is used.
When the full dose of a narcotic isn;t used. another nurse must withness and sign that the unused portion is discarded.

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postpartum care:

the tubes should not be removed until you know if there will be an autopsy. Also different institution has different policy about removal tubes.

The priority postpartum care: place the body in proper anatomical alignment.

a woman is receiving doxorubicin (adriamycin) i.v. for cancer therapy. You note swelling and redness at the insertion site. After further assessment, you confirm that extravasation has occured. What do you do next?

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Caring for a pt. with radiation implant. which instruction is the best:

a. Use gloves to handle radioactive material

b. keep all linen in the room during treatment.

c. keep an aluminum-lined container in the room for radiation material

d. Stand at the foot of the bed rather than on the side when providing care.

-answer: B.
Linens are kept in the room so they can be examined in case radiation material dislodges.

Radiation material should only be handled by forceps, never with the hands, even with gloves.

A container for radiation material is lined with lead. Standing at the foot of the bed rather than on the side doesn't decrease your exposure to radiation.

To limit the exposure, you must limit the tmie exposed. keep yourself shielded when possible, and remain at the greatest possible distance from the patient.

as a team leader, which method conserve time when delegating assignments?
a. assign unfinished work to other team members.

b. Explain to all team members what need to be done.

c. Relinquish responsibility for the outcome of the work.

d. Assign each team member the responsibility to obtain meal trays.

-answer: B

terms:

Dehiscence: opening of the wound.

Evi

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During a physical examination, the nurse asks a client to hold the breath briefly, and then uses a stethoscope to auscultate over the carotid arteries. Which finding isnormal when auscultating over these arteries?

1. No sounds heard over either carotid artery

2. Faint swishing sounds heard over both carotid arteries

3. Throbbing pulsations heard bilaterally

4. Louder sounds heard over the right carotid artery than over the left carotid artery

The nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure?

1. Wrapping the cuff around the limb, with the uninflated bladder covering about one-fourth of the limb circumference

2. Measuring the arm about 2" (5 cm) above the antecubital space

3. Wrapping the cuff around the limb, with the uninflated bladder covering about three-quarters of the limb circumference

4. Using a bladder that is 6" (15 cm) long.

Correct Answer: 3
When measuring blood pressure, the nurse should wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-quarters (not one-fourth) of the limb circumference. Bladder size is chosen according to the size of the extremity.

The nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should:

1. have the client inhale during auscultation.

2. palpate the radial artery during auscultation.

3. use the bell of the stethoscope.

4. use the diaphragm of the stethoscope.

Correct Answer: 3
With the client holding his breath, the nurse uses the bell of the stethoscope to auscultate the carotid arteries for bruits. Having the client inhale would interfere with sound detection. Palpating the radial artery wouldn't yield significant information and could interfere with the nurse's ability to listen without interruptions or distractions. The nurse uses the diaphragm of the stethoscope to detect high-pitched sounds, such as breath and bowel sounds.

Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

1. keep the client warm.

2. maintain room temperature at 78° F (25.6° C).

3. keep the client uncovered.

4. match the room temperature with the client's body temperature.

Correct Answer: 1
The nurse should keep the client covered and expose only the portion of the client's body that is being assessed. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could influence the client's response. A room temperature of 78° F may be too warm for some clients and too cool for others. Keeping the client uncovered would lead to chilling. Matching the room temperature with the client's body temperature is inappropriate.

The ear canal of an infant or young child:

1. slants upward.

2. slants downward.

3. is horizontal.

4. slants backward.

Correct Answer: 1
The ear canal slants up in a younger child and down in an older child or adult.

Heberden's nodes appear on the distal interphalangeal joints. These bony and cartilaginous enlargements are usually hard and painless and typically occur in middle-aged and elderly clients with osteoarthritis.

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The nurse can auscultate for heart sounds more easily if the client is:

1. supine.

2. on his right side.

3. holding his breath.

4. leaning forward.

answer: 4

Lordosis is characterized by an accentuated curve of the lumbar area of the spine.

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The nurse is assessing a client's pulse. Which pulse feature should the nurse document?

1. Timing in the cycle

2. Amplitude

3. Pitch

4. Intensity

Correct Answer: 2
The nurse should document the rate, rhythm, and amplitude of a client's pulse. Pitch, timing, and intensity aren't associated with pulse assessment.

Which statement regarding heart sounds is correct?

1. S1 and S2 sound equally loud over the entire cardiac area.

2. S1 and S2 sound fainter at the apex.

3. S1 and S2 sound fainter at the base.

4. S1 is loudest at the apex, and S2 is loudest at the base.

The S1 sound — the "lub" sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2. The S2 — the "dub" sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.

Which of the following sentences correctly describes the anatomic position?

1. The body is supine.

2. Arms are elevated at shoulder level.

3. Palms are turned forward.

4. The body is facing backward

Correct Answer: 3
In the anatomic position, the body is erect, facing forward with arms at the sides and palms turned forward.

A client who was involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to whichlobe of the brain?

A 76-year-old client with no debilitating conditions belongs to which geriatric population?

1. Young-old

2. Middle-old

3. Old-old

4. Frail elderly

Correct Answer: 2
A 76-year-old client with no debilitating conditions belongs to the middle-old geriatric population. The young-old geriatric population ranges in age from 65 to 74; the middle-old from 75 to 84; and the old-old from 85 and older. Within each of these three subgroups is another group, the frail elderly, which includes all individuals over age 65 who have one or more debilitating conditions.

Romberg's sign
A swaying (or falling) when a person stands with feet together and eyes closed. It's an indication that the person has lost a sense of position. Also called rombergism.

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When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nursesuspects:

The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal aging change is:

1. cloudy vision.

2. incontinence.

3. diminished reflexes.

4. tremors.

-Correct Answer: 3
egenerative changes can lead to decreased reflexes, which is a normal result of aging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlying pathology.

Erb's point is located at the third left intercostal space, close to the sternum. Murmurs of both aortic and pulmonic origin may be heard at Erb's point.

-

Which plane divides the body longitudinally into anterior and posterior regions?

1. Frontal plane

2. Sagittal plane

3. Midsagittal plane

4. Transverse plane

-Correct Answer: 1
A frontal or coronal plane runs longitudinally at a right angle to a sagittal plane, dividing the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

Using posterior landmarks, the lungs extend from the cervical area to the level of the 10th thoracic vertebrae (T10) at the end of expiration.

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The nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test?

The nurse prepares to palpate a client's maxillary sinuses. For this procedure, where should the nurse place the hands?

1. On the bridge of the nose

2. Below the eyebrows

3. Below the cheekbones

4. Over the temporal area

Correct Answer: 3
-To palpate the maxillary sinuses, t
he nurse places the hands on either side of the client's nose below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places the thumb just above the client's eye under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

When palpating a client's body to detect warmth, the nurse should use which part of the hand?

1. Fingertips

2. Finger pads

3. Back (dorsal surface)

4. Ulnar surface

Correct Answer: 3
To feel for warmth, the nurse should use the back, or dorsal surface, of the hand. The fingertips are best for distinguishing texture and shape; the finger pads, for assessing hair texture, grasping tissues, and feeling lymph node enlargement; and the ulnar surface, for feeling thrills and fremitus.

A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client's baseline arm blood pressure, the nurse should expect thethigh to have a:

1. higher systolic blood pressure reading.

2. higher diastolic blood pressure reading.

3. lower systolic blood pressure reading.

4. lower diastolic blood pressure reading.

Correct Answer: 1
Systolic readings in the thigh may be 10 to 40 mm Hg higher than in the arm. Diastolic readings are the same in the arm and thigh.

A mother comes to the clinic with her 5-year-old son who's complaining of a fever and sore throat. The nurse documents the client's tonsils as3+. This means they're:

1. barely visible outside the tonsillar pillar.

2. halfway between the tonsillar pillar and the uvula.

3. touching the uvula.

4. touching each other.

Correct Answer: 3
Tonsils that touch the uvula are rated 3+. Tonsils barely visible outside the tonsillar pillar are rated 1+. Tonsils between the tonsillar pillar and the uvula are rated 2+. Tonsils that touch each other are given a 4+ rating.

When percussing a client's chest, the nurse should identify which sound as a normal finding?

1. Hyperresonance

2. Tympany

3. Resonance

4. Dullness

Correct Answer: 3
Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in emphysema. The nurse may assess tympany when percussing over the abdomen, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.

When assessing a geriatric client, the nurse expects to find various aging-related physiologic changes. These changes include:

When assessing the facial lacerations of a middle-aged client admitted to the facility 1 week ago, the nurse observes scabs around the lacerations. Scabs indicate which phase of wound healing?

1. Contraction

2. Fibrinoplastic

3. Lag

4. Inflammation

Correct Answer: 3
At the end of the lag phase, the fibrin network dries out and forms a scab. The fibrinoplastic phase concludes with a scar, and the contraction phase is demonstrated by sloughing and shrinking of the scar. Inflammation is the first stage of wound healing and includes hemostasis, edema, and drawing of leukocytes to the wound area.

The murmur of aortic stenosis is low-pitched, rough, and rasping. It's heard loudest in the second intercostal space to the right of the sternum.

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The ear canal of an infant or young child:

1. slants upward.

2. slants downward.

3. is horizontal.

4. slants backward.

Correct Answer: 1
-The ear canal slants up in a younger child and down in an older child or adult.

The nurse measures a client's apical pulse rate and compares it with the radial pulse rate. The differential between these two pulses is called:

1. the pulse pressure.

2. the pulse deficit.

3. the pulse rhythm.

4. pulsus regularis.

-Correct Answer: 2
The differential between the apical and radial pulse rates is called the pulse deficit. Pulse pressure refers to the differential between systolic and diastolic blood pressures. Pulse rhythm is the interval pattern between heartbeats. Pulsus regularis is the normal pulse pattern, in which the interval between beats is consistent

When a nurse enters the client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes:

1. the history of the present problem, medications, review of systems, and recent major operations.

2. the history of the present problem, allergies, medications, and recent major operations.

3. the history of the present problem, medications, family history, psychosocial history, and review of systems.

4. the history of the present problem, allergies, medications, review of systems, and recent major operations

-Correct Answer: 2
After assessing the client's chief complaint, the nurse should review the client's pertinent medical history; allergies, including a description of any reactions; any illness requiring treatment; major surgeries performed, including why and when; and current medications (both prescription and over-the-counter) and their purposes. This information allows the nurse to establish a baseline and determine the cause and urgency of the client's problem.

The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

1. coma or seizures.

2. sunken eyeballs and poor skin turgor.

3. increased heart rate with hypotension.

4. thirst or confusion.

Correct Answer: 4
Early signs and symptoms of dehydration include thirst, irritability, confusion, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor, and increased heart rate with hypotension are all later signs.

Heberden's nodes appear on the distal interphalangeal joints. These bony and cartilaginous enlargements are usually hard and painless and typically occur in middle-aged and elderly clients with osteoarthritis

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During the planning step of the nursing process, the nurse takes which step?

1. Determines the client's goal achievement

2. Writes a statement about the client's health problem

3. Establishes short- and long-term goals

4. Gathers objective data

Correct Answer: 3
During the planning step of the nursing process, the nurse establishes priorities and short- and long-term goals, projects measurable outcomes, and develops a care plan. The nurse determines the client's goal achievement during the evaluation step, writes statements about the client's health problem during the nursing diagnosis step, and gathers objective data during the assessment step.

Which type of evaluation occurs continuously throughout the teaching and learning process?

1. Formative

2. Retrospective

3. Summative

4. Informative

Correct Answer: 1
Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative isn't a type of evaluation.

The nurse identifies a client's responses to actual or potential health problems during which step of the nursing process?

1. Assessment

2. Analysis

3. Planning

4. Evaluation

Correct Answer: 2
The nurse identifies human responses to actual or potential health problems during the analysis step of the nursing process, which encompasses the ability of the nurse to formulate a nursing diagnosis. During the assessment step, the nurse systematically collects data about the client or family. During the planning step, the nurse develops strategies to resolve or decrease the client's problem. During the evaluation step, the nurse determines the effectiveness of the care plan.

dysphagia.

aphasia:

aphasia: Inability to speak clearly

dysphagia: Difficulty swallowing

A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions?

1. Asking frequently whether the client understands the instructions

2. Asking an interpreter to relay the instructions to the client

3. Writing out the instructions and having a family member read them to the client

4. Demonstrating the procedure and having the client return the demonstration

Correct Answer: 4
Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly. Clients may claim to understand discharge instructions when they don't. An interpreter or family member may communicate verbal or written instructions inaccurately.

The nurse may use one of many nursing theories to guide client care. What are the four key concepts of most nursing theories?

During the planning step of the nursing process, the nurse performs which activity?

1. Records data

2. Develops goals of care

3. Collects data

4. Carries out interventions

Correct Answer: 2
During the planning step of the nursing process, the nurse determines care priorities, develops goals of care, and selects appropriate interventions to achieve these goals. The nurse collects and records data during the assessment step of the nursing process. The nurse carries out interventions during the implementation step.

Correct Answer: 1
A heart rate of 144 beats/minute indicates decreased diastolic filling time and a reduced blood volume ejected with each contraction, resulting in decreased cardiac output. The client's temperature and respiratory rate are elevated but not enough for a diagnosis of Ineffective thermoregulation or Ineffective breathing pattern to take precedence over one of Decreased cardiac output. The client's vital signs don't suggest a diagnosis of Ineffective renal tissue perfusion

A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse shouldquestion which physician order?

1. "Monitor urine output every hour."

2. "Infuse I.V. fluids at 83 ml/hour."

3. "Administer oxygen by nasal cannula at 3 L/minute."

4. "Draw samples for hemoglobin and hematocrit every 6 hours."

Correct Answer: 2
Because shock signals a severe fluid volume loss (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. The other options are appropriate orders for this client

The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:

1. change his own dressing.

2. walk in the hallway.

3. walk from his room to the end of the hall and back before discharge.

4. eat a special diet.

Correct Answer: 3
Walking from his room to the end of the hall and back before discharge is a specific, measurable, attainable, and timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.

A client is placed on a low-sodium (500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has beeneffective?

1. "I can still eat a ham-and-cheese sandwich with potato chips for lunch."

2. "I chose broiled chicken with a baked potato for dinner."

3. "I chose a tossed salad with sardines and oil and vinegar dressing for lunch."

4. "I'm glad I can still have chicken bouillon soup."

Correct Answer: 2
The client's choice of a baked potato with broiled chicken indicates effective nutrition teaching because potatoes and chicken are relatively low in sodium. Ham, sardines, and bouillon are extremely high in sodium and shouldn't be included in a low-sodium diet.

Which option serves as a framework for nursing education and clinical practice?

1. Scientific breakthroughs

2. Technological advances

3. Theoretical models

4. Medical practices

Correct Answer: 3
Theoretical models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren't frameworks for nursing education and practice.

What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

1. Deficient fluid volume

2. Excess fluid volume

3. Decreased cardiac output

4. Ineffective gastrointestinal tissue perfusion

Correct Answer: 1
Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. The volume deficit may be caused by vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?

1. Security

2. Elimination

3. Safety

4. Belonging

Correct Answer: 2
According to Maslow, elimination is a first-level, or physiologic, need and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after the client's first-level needs have been satisfied.